Breast Cancer: What Psychiatrists Need to Know

Breast Cancer: What Psychiatrists Need to Know

One of my patients was recently
listening to a television program
on breast cancer. The oncologist
on the program noted that this was the
best time in history to have breast cancer
because of the exciting new treatments,
imaging techniques, improvement in
survival rates, and the appreciation that
breast cancer is probably a heterogeneous
disease. My patient said this is
all great news—but would this help her
live to see her children graduate from
elementary school?

Many of our female patients are more
worried about getting breast cancer than
having cardiovascular disease. Breast
cancer is so common that almost everyone
reading this article will eventually
know someone with this disease, whether
it is a family member, close friend,
colleague, or neighbor. It may even
strike one of us. For a session at the
upcoming American Psychiatric Association
annual meeting in Toronto, we
asked some of our colleagues to talk
about their own experiences with cancer.
Three of the panel members have themselves
survived breast cancer.

Why are we so terrified of breast
cancer? The disease interweaves
complicated emotional, physical,
genetic, and cosmetic factors. As practicing
psychiatrists, it is almost certain
that we will, at some point, care for
patients who are receiving treatment for,
or who have a history of, breast cancer.
In this article, we review some of the
major issues for psychiatrists to
consider. Men, of course, may also get
breast cancer, but in much smaller
numbers. Consequently, we will focus
solely on breast cancer in women.

A closer look at breast cancer

Breast cancer is the most commonly
diagnosed cancer in women and
accounts for approximately 15% of all
cancer deaths in the United States.1 In
2005 alone, an estimated 211,000
women received a diagnosis of breast
cancer2 and an estimated 40,000 died of
the disease.3 Let's look at several aspects
of breast cancer and its treatment.
An estimated 5% to 10 % of women
with breast cancer have an inherited
mutation in a cancer susceptibility gene.4
Mutations in the BRCA1 and BRCA2
genes account for most of these cases.5
As a result, women who know they carry
these mutations probably understand
that their lifetime risk of breast cancer
is as high as 85%.6,7

In certain families, multiple female
relatives receive a diagnosis of breast
cancer, sometimes at an early age, despite
the absence of mutations in the BRCA1 and BRCA2 genes. These malignancies
appear to be more genetically heterogeneous
than those associated with theBRCA1 and BRCA2 genes.5,8

Depending on a patient's particular
circumstances, breast cancer treatment
may include surgery, radiotherapy,
chemotherapy, or hormonal therapy.
These treatment modalities have
improved outcomes in patients with breast
cancer. When breast cancer metastasizes,
however, survival is limited.9 More than
half of women with metastatic breast
cancer, for example, have hepatic involvement,
which makes treatment even more
difficult.10 And while sentinel-node
mapping helps reduce the risk of unsightly or disabling lymphedema, it does not
eliminate this condition.

Important new findings about the
epidermal growth factor receptor
HER2, which plays a crucial role in the
regulation of cell proliferation and
survival, are changing breast cancer
treatment. Overexpression of HER2
correlates strongly with poorer prognosis
in breast cancer. Use of anti-HER2
agents, such as trastuzumab, or combining
HER2 blockers with other agents
may overcome the tumor's compensatory
or resistance mechanisms, thereby
increasing the efficacy of anti-HER2
therapies. The bottom line is that oncologists
can correlate HER2 findings
with tumor resistance to chemotherapy
and make better predictions. This helps
tailor therapies and treatment for individual
patients.11